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. 2015 Jun;3(3):E195-201.
doi: 10.1055/s-0034-1391668. Epub 2015 Apr 13.

Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study

Vivek Kumbhari  1 , Alan H Tieu  1 , Manabu Onimaru  2 , Mohammad H El Zein  1 , Ezra N Teitelbaum  3 , Michael B Ujiki  4 , Matthew E Gitelis  4 , Rani J Modayil  5 , Eric S Hungness  3 , Stavros N Stavropoulos  5 , Hiro Shiwaku  6 , Rastislav Kunda  7 , Philip Chiu  8 , Payal Saxena  1 , Ahmed A Messallam  1 , Haruhiro Inoue  2 , Mouen A Khashab  1
Affiliations

Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study

Vivek Kumbhari et al. Endosc Int Open. 2015 Jun.

Abstract

Background and study aims: Type III achalasia is characterized by rapidly propagating pressurization attributable to spastic contractions. Although laparoscopic Heller myotomy (LHM) is the current gold standard management for type III achalasia, peroral endoscopic myotomy (POEM) is conceivably superior because it allows for a longer myotomy. Our aims were to compare the efficacy and safety of POEM with LHM for type III achalasia patients.

Patients and methods: A retrospective study of 49 patients who underwent POEM for type III achalasia across eight centers were compared to 26 patients who underwent LHM at a single institution. Procedural data were abstracted and pre- and post-procedural symptoms were recorded. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤ 1. Secondary outcomes included length of myotomy, procedure duration, length of hospital stay, and rate of adverse events.

Results: Clinical response was significantly more frequent in the POEM cohort (98.0 % vs 80.8 %; P = 0.01). POEM patients had significantly shorter mean procedure time than LHM patients (102 min vs 264 min; P < 0.01) despite longer length of myotomy (16 cm vs 8 cm; P < 0.01). There was no significant difference between POEM and LHM in the length of hospital stay (3.3 days vs 3.2 days; P = 0.68), respectively. Rate of adverse events was significantly less in the POEM group (6 % vs 27 %; P < 0.01).

Conclusions: POEM allows for a longer myotomy than LHM, which may result in improved clinical outcomes. POEM appears to be an effective and safe alternative to LHM in patients with type III achalasia.

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Conflict of interest statement

Competing interests: M. Khashab is a consultant for Boston Scientific, Xlumena and Olympus America and has received research support from Cook Medical. H. Inoue is a founding member, equity holder, and consultant for Apollo Endosurgery. No other financial relationships relevant to this article were disclosed.

Figures

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Fig. 1 Manometric and endoscopic findings in a patient with type III achalasia. a High intensity spastic contraction (DCI of 30,000) with elevated lower esophageal sphincter baseline pressure typical of type III achalasia. b Endoscopic view during an episode of spastic contraction in the midesophagus.
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Fig. 1 Manometric and endoscopic findings in a patient with type III achalasia. a High intensity spastic contraction (DCI of 30,000) with elevated lower esophageal sphincter baseline pressure typical of type III achalasia. b Endoscopic view during an episode of spastic contraction in the midesophagus.
Fig. 2
Fig. 2
Treatment of a patient with spastic esophageal disorder. a Long submucosal tunnel performed during peroral endoscopic myotomy. b Translumination observed 3 cm below the esophagogastric junction indicating extension of myotomy into the proximal stomach.
Fig. 3
Fig. 3
Myotomy during peroral endoscopic myotomy. a Selective inner circular myotomy. b Full thickness myotomy.
Fig. 4
Fig. 4
Intraoperative image of the myotomy during transabdominal laparoscopic Heller myotomy.
Fig. 5
Fig. 5
Flow diagram depicting the criteria used to include patients suitable for analysis.
See this image and copyright information in PMC

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